Basic Information
| Provider Information | |||||||||
| NPI: | 1528306222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOUGH'S FAMILY AND PEDIATRIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | DREW | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387370068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627456638 | ||||||||
| FaxNumber: | 6627458480 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DREW | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387373146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627456638 | ||||||||
| FaxNumber: | 6627458480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOUGH | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6627456638 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 06639 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.